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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> Sealing No.County Name2210133 <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. H <br /> HENNEPIN Minnesota Statutes,Chapter 1031 or W-series No. <br /> lil*We blank If brown) <br /> Township Name Township No. Range No. Section No. Fraction(sm-).Ig) Date Sealed Date Well or Boring Constructed <br /> ORONO 117 23 02 "' SE' MN' Thursday,July 22..2004 <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing 1131 ft. Original Depth taMi- record ff. <br /> Longitude degrees minutes seconds AQUIFERS) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location i Single Aquifer 0 M4ltiaquifer <br /> 320 ROAD WELUBORING [ Measured 0 Estimated <br /> lX Water Supply Well L]Monit.Well <br /> Show exact location'of well or boring Sketch map of well or boring 70 <br /> in section grid with"X location,showing property 0 Env.Bore Hole El Other ft. [below .❑above land surface <br /> N lines,roads,and buildings. <br /> CASING TYPES) <br /> :4:) - <br /> I a ICH' Steel L]Plastic ❑Tile ❑Other <br /> W I E <br /> WELLHEAD COMPLETION <br /> ' i Outside: 0 Well House 'Inside: <br /> -1--- ---l----�-- ❑Basement Offset <br /> f I i f *M4' • dr h01ts6 i Pitless Adapter/Unit Well Pit <br /> --I--" i i--. <br /> ' I ❑Well Pit ❑Buried <br /> S <br /> 1.*--- a ❑BUried r <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> JAY;BEFL1AtAit4 Diameter Depth Set in oversize hole? Annular space initially'grouted? <br /> P9 W <br /> Property owner's mailing address if different than well location address indicated above �•:�ih.from__S to 161 ft. - <br /> 320 ORONO ORCHARD ROAD Yes C o • ❑Yes 0 No ❑Unknown <br /> WAYZAtA,MN 55391 in.from to ft. 0 Yes <br /> ❑No ❑Yes 0 No ❑Unknown <br /> in.from to ft. fl Yes ❑No ❑Yes; 0 •No, ❑Unknown <br /> . <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> 15. 1•01 <br /> Welt owner's mailing addres's if different than-progeny owner's address indicated above - Screen from - to •ft. Open Hole from - to . ' ft. ' <br /> SAS OBSTRUCT)ONS ..` , <br /> ERods&brop Pipe' '❑Check Valve(s) ❑Debris ❑,Fill •,❑ No,Obstruction .. <br /> Rein lied 108',X 1.25":D1wp Pipe i A.Siih a T 1B'PnRmP--- <br /> Type of Obstructions(Describe) <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLOR FROM TO Obstructions removed? l3 res0 No Describe . <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or bong PUMP _ <br /> 00tyC3aYWi0iSand `�3rOVM.,. 0 T. 3: e� tutlp. ., <br /> d(Removedi 0,Not Present .:- El,Other <br /> METHOD USED T O SEAL;ANNULAfRSSPACEBE tWEEN 2 CASINGS,Pit CASING,MoiEICIRE}'IOlx:- , <br /> Sand( &ElaY Vaned 65 95 jjksfo Annylar Space Exists•. <br /> p 0 Annular space grouted.wlth tremie pipe 'E] Casing RertoretiorVRemovals <br /> (aay . 1410 ' in.from . to ft. 0 Perforated '.0 Removed <br /> Sand&`Gravel M• <br /> arie• <br /> 140 155 in,from to ft. El Perforated Removed <br /> Sandy Cast WllWIG _ 155 160Typ'e o)perforator <br /> . <br /> Dred-07:13:404 ❑ Other <br /> t78ptlt-4 x-t: 5a: GROUTING`MATERIAL(S) ; '((One bag of cefnent,94 ;one lbs bag of ben t elif a 50 lbs) <br /> Grouting Material 1 from 6 to. -`8 5 - 0:0016'. ' <br /> SCWBn-1 5.4551yards bags <br /> Static Wati�. 70' from 5.5 161 0 49q <br /> t4 fti yards bags <br /> from to ft. 8yards bags <br /> ' INFORMA'I1OIIfR U:;REPIA( aer4T'WBL 07.13.04 OTHER.WEL:LSANb BORINGS • . <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unseated and unused well or boring on property? g Yee .0 lip' How many2 <br /> well located it <br /> 100141 on rlOrttl'side of basement LICENSED OR REGISTERED CONTRACTOR CER1TflCAT10N <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> vAta depth Measured from grade1ewd true to the best of my knowledge. <br /> rndh s leas not on site d! wen i ltl8i�the Wiaiar (763)493.3650 27800 <br /> Contractor Business Name License or Registration No. <br /> vie( Cation of notification was Received fn nl mdh <br /> July 2Z 2004 <br /> 02 117 23 24 0002 <br /> Authorized Representative Signature Date <br /> LOCAL COPY H 221083 .Name of Person Sealing Well or Boring <br />